Hypertension

Acute Management

Diagnosis

1. Severity

   • Hypertension emergency

   • Hypertension urgency

2. Cause

   • (Primary) Essential Hypertension

   • Secondary Hypertension

     1. Acute

     2. Chronic

Essential Hypertension

Background

• Essential Hypertension is by far the commonest cause of hypertension and unless young, the presumed cause of the hypertension

• Uncontrolled hypertension is likely the modifiable risk factor associated with the highest morbidity and mortality

• Uncontrolled hypertension causes chronic damage to the vital organ systems: nervous, cardiovascular, respiratory, renal and liver systems

Assessment

Presentation

• Asymptomatic, usually found on screening

• Hypertensive emergency: headaches, chest pain, frothy urine

Examination

• BP > 140/90, consider ambulatory BP or 24hr monitoring

Investigations

• Hypertensive Emergency

  • ECG: LVH

  • CT-H: hypertensive encephalopathy

  • UA: protein; albumin: Cr ratio- raised protein

Management

Chronic: NICE 2019

1.  ACEi or CCB

   1. ACEi if < 55yrs or diabetic

   2. CCB if > 55yrs + Afro-Caribbean

2. ACEi + CCB

3. Add thiazide like diuretic

4.  K+ < 4.5: spironolactone, K+> 4.5 doxazocin/ beta blocker

5. Refer to specialist

Comments

• Thiazide like diuretic preferred to thiazide due thiazides effect on glycemic control

Secondary Causes of Hypertension

Treatment Resistant Hypertension

• Definition: BP > 140/90 following 3+ antihypertensives

• Secondary causes of hypertension should be considered in treatment resistant hypertension

Acute

• Stroke

  • Ischaemic: tolerate BP 210/ 120

  • Ischaemic for thrombolysis: < 185/110

  • Hemorrhagic: < 140/90

  • SAH: SBP < 160

• Aortic Dissection: SBP 100-120 (betablockers)

• Drugs

  • Stimulants: coffee, nicotine, MDMA, cocaine

Note sepsis usually caused hypotension > hypertension

Chronic Causes of Secondary Hypertension

• Renal

  • Chronic Kidney Disease

    • Diabetic Nephropathy

    • Glomerulonephritis

    • Polycystic Kidney Disease

    • Obstructive uropathy- BPH, intrabdominal cancer

    • Renal Cell Cancer

    • Liddle Syndrome

    • Reflux Nephropathy

    • Liquorice (pseudohyperaldosteronism)

• Endocrine

  • Hyperaldosteronism

    • Bilateral Adrenal Hyperplasia 

    • Conn's Syndrome: (adrenal tumour)

  • Phaeochromocytoma: adrenal tumour secreting catecholamines

  • Cushing's Syndrome

  • Acromegaly

  • Hypo/hyperthyroidism

• Metabolic

  • Obstructive Sleep Apnea (OSA) 

  • Anxiety Disorders

  • Metabolic Syndrome

  • Exogenous steroids

  • Alcohol

• Vascular: 

  • Coarctation of Aorta

  • Renal Artery Stenosis

Complications

Acute

• Stroke

• Coronary Artery Disease

• Cardiac arrhythmias: AF

Chronic

1. Nervous System

   1. Hypertensive Encephalopathy ->  Vascular Dementia

   2. Peripheral Neuropathy

   3. Hypertensive Retinopathy

2. Cardiovascular

   1. Hypertensive Cardiomyopathy: CHF

   2. Peripheral Vascular Disease

3. Hypertensive Nephropathy: CKD

4. Frailty, End of Life Care 

Hypertension in Pregnancy

If BP > 140/90

1. Labetalol

2. Methyl dopa

3. Other alternatives: hydralazine, nifedipine

Not safe in pregnancy: ACE inhibitors, ARBs

Page written in 2024.